Provider Demographics
NPI:1194219089
Name:GOODRICH, BRIANA PAIGE
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:PAIGE
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10440 QUEENS BLVD APT 2X
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-8138
Mailing Address - Country:US
Mailing Address - Phone:516-521-9451
Mailing Address - Fax:
Practice Address - Street 1:4300 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-5704
Practice Address - Country:US
Practice Address - Phone:516-210-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant